l’imaging quale premessa alla clinica dell’infertilità · abnormalities in the human male...

Department of Urology – University of Trieste - Italy(Direttore: Prof. E. Belgrano)

C. TrombettaE. Belgrano

L’imaging quale premessa alla clinica dell’infertilità

– vasography– scrotal ultrasound– plebography– transrectal ultrasound– NMR

Imaging techniques for the assessment of male infertility

Vasography

in the presence of obstructive azoospermia always … before microsurgery

evidence of increased associated abnormalities in the human male genitourinary tract:

➜ microlithiasis➜ testicular cancer➜ cryptorchidism➜ varicocele➜ hydrocele➜ epididymal abnormalities

role of ultrasound in the assessment of male infertility

can be detected sonographically

Gordon SJ; BJU international 2001

ultrasound is an important diagnostic tool in evaluation of infertile male patient➜oligospermic patients

etiologic diagnosis improve quality of semen

➜azoospermic patients distinguish non obstructive/obstructive

azoospermia


transrectal ultrasound➜document the absence of seminal vesicles

and vas deferens➜evaluation of ejaculatory duct obstruction

scrotal ultrasound➜gold standard imaging technique for scrotal

disease➜may be helpful in distinguishing testicular

failure from obstructive azoospermia direct demonstration of abnormalities in the

proximal genital tract secondary changes of the proximal genital duct

caused by obstruction in the distal part


testicular volume➜ 15 – 25 ml➜ accuracy of ultrasound is within 10% of

actual volume and is better than physical examination

➜ testicular size has been shown to correlate with testicular function

scrotal ultrasound

Schiff JD; Andrology 2004

Arai T; Int J Fertil 1998

(0,52 X A X B X C): 14-25 ml

evaluation of testicular volume➜ conditions associated with atrophy

and infertility: varicocele cryptorchidism post-pubertal mumps Klinefelter Syndrome hepatic cirrhosis

scrotal ultrasound

Kim ED; J Clin Ultrasound 1996

localization of inguinal, undescended testis

scrotal ultrasoundnot palpable testes

Kim ED; J Clin Ultrasound 1996

evaluation of testicular after trauma

scrotal ultrasound

Asian J Androl. 2014 Jul-Aug; 16(4): 650–651. Fertility preservation after bilateral severe testicular traumaGiovanni Liguori, Nicola Pavan, Gianluca d’Aloia, Stefano Bucci,Bernardino de Concilio, Giorgio Mazzon, Giangiacomo Ollandini, and Carlo Trombetta

Peritesticular hematoma; internal heterogenous structure; contour irregularities; parenchimal ischemia

scrotal ultrasound

rare situation, usually from motorbike accidents normal but empty scrotal sac; testis displaced cranially Often misdiagnosed situation:

➜ No signs of scrotal trauma➜ Impossibility to palpate the trumatized scrotum

scrotal ultrasound

evaluation of testicular irregularities on physical examination➜ nodules➜ indurations➜ masses

excellent differentiation between intratesticular and extratesticular masses

increased association between testis tumor and infertility is well-established

scrotal ultrasound

Lambert SM; Urol Clin North Am 2007

ultrasound appearance of testicular tumors➜ focal hypoechoic lesion (seminoma)

➜ inhomogeneous echotexture (71%)➜ irregular margins (45%)➜ echogenic foci (35%)➜ cystic components (61%)

scrotal ultrasoundtesticular tumor

Dogra VS; Radiology 2003

NSGCT

scrotal ultrasoundtesticular tumor pre-operative

cryopreservation

CLINICA UROLOGICAUniversità degli Studi di Trieste

(1989 - 2003)

Risultati: spermiogramma

post-orchiectomia (53 pz) Media: 17.9 milioni/ml

s p e r m io g r a m m a p o s t

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 5 9 13 17 21 25 29 33 37 41 45 49 53

p a z ie n t i

mili

oni/m

l

s p e rm io g ra m m i p re

0

2 0

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 3 5 7 9 1 1 1 3 1 5 1 7 1 9 2 1 2 3 2 5 2 7 2 9 3 1 3 3 3 5 3 7 3 9

p a z ie n t i

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oni/m

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pre-orchiectomia (40 pz) Media: 24.9 milioni/ml

scrotal ultrasoundtesticular tumor

intraoperative ultrasound of non palpable masses➜ to clamp funicular structures ➜ to detect the tumor ➜ to perform excision➜ to wait pathologist answer

nerve-sparing

laparoscopynot nerve-sparing technique

anejaculation andtesticular tumor

microlithiasis (calcifications of seminiferous tubules)➜ multiple, diffuse, nonshadowing foci➜ effect on spermatogenesis is still unclear

direct toxic effect of the microliths within the seminiferous tubules

immunologic mechanism

scrotal ultrasoundbenign intratesticular lesions

Sakamoto S; Urology 2007

intratesticular cysts➜ cysts of the tunica albuginea➜ cysts of the rete testis➜ epidermoid cysts

scrotal ultrasoundbenign intratesticular lesions

the most common identifiable anatomic abnormalities in male factor infertility➜ 40 % of infertile men

diagnosis of palpable varicocele is important➜ treatment improve sperm quality in as many as 53%

of pts

relationship between nonpalpable (subclinical) varicocele and infertility remains controversial

scrotal ultrasoundvaricocele

Wagner L; Progr Urol 2007

sensitivity and specificity of 100% for varicocele detetection with CDUS

multiple, hypoechoic, serpiginous, tubular structure of varying sizes (> 2 mm)

phasic variation and retrograde filing during Valsalva


US

CDUS

Liguori G; World J Urol 2004

CDUS imaging is now the gold standard for the diagnosis of varicocele

varicocele can be divided into 5 gradesaccording to the characteristics of the reflux and its length, and to changes during Valsalva’s manoeuvre


Sarteschi LM; Ecografia Andrologica 2003

Grade 1 scrotal varicosity not evident in the grey-scale study prolonged reflux in vessels in the inguinal channel only during

Valsalva’s manoeuvre

scrotal ultrasoundvaricocele - CDUS

Grade 2 small posterior varicosity that reaches the superior pole of the

testis and increases after Valsalva venous reflux in the supratesticular region only during

Valsalva


scrotal ultrasoundvaricoceleGrade 3 vessels that appear enlarged to the inferior pole of the

testis when the patient is evaluated in a standing position

no ectasia is detected in a supine position a clear reflux only under Valsalva’s manoeuvre

Valsalva

scrotal ultrasoundvaricoceleGrade 4 enlarged vessels even in a supine position dilatation increases in an upright position and during

Valsalva enhancement of the venous reflux after Valsalva hypotrophy of the testis is common at this stage

scrotal ultrasoundvaricoceleGrade 5 evident venous ectasia even in a supine position important basal venous reflux that does not increase

after Valsalva

scrotal ultrasoundvaricoceleIntratesticular varicocele: evaluation using grey scale and color Doppler ultrasound. Bucci S, Liguori G, Amodeo A, Salamè L, Trombetta C, Belgrano E.

World J Urol. 2007 Oct 26

retrograde phlebography is

performed in the same direction of the reflux

1. dilation of ISV

2. presence of more than one ISV

scrotal ultrasoundhydrocele

higher incidence in infertile pts compared with controls (16.7 vs 8.7 %)

can affect spermatogenesis➜liquid pressure in the tunica vaginalis➜warm environment➜drop in testicular circulation

Qublan HS; J Clin Ultrasound 2007

scrotal ultrasoundepididymal cyst

may cause partial or complete obstruction of the seminal pathways

transrectal ultrasound

urologists are familiar with the use of TRUS for the assessment of prostatic malignancy

excellent visualization of the seminal vesicles, prostate and ejaculatory ducts

➜ to assess obstruction➜ to determine the absence or hypoplasia of the

seminal vesicles and ejaculatory ducts


absolute indications abnormal DRE

➜midline cyst or asymmetry

low volume azoospermia low volume severe oligoasthenospermia

➜in the absence of testicular atrophy

➜retrograde ejaculation not present


relative indications normal volume azoospermia/

oligoasthenospermia➜in the absence of testicular hypotrophy

anejaculation, hematospermia, painful ejaculation

history suggestive of genital tract abnormality


Kuligowska E. Radiology 1998

trasversal and sagittal ultrasound shows a midline cyst in a 29-year old man

fluid aspiration from the cyst did not contain sperm

Mullerian or utricular prostatic cysts

scrotal US abnormalities in obstructive azoospermia compared with NON obstructive azoospermia

abnormalities in the epididymal head, body and tail testicular volume

tubular ectasia in the epididymal head

enlarged, coarsely hypoechoic epididymal head suggestive of an inflammatory mass

scrotal US abnormalities in obstructive azoospermia compared with NON obstructive azoospermia

Moon MH; Radiology 2006

“…. evaluation of the epididymis and testicular volume with scrotal US are important in distinguishing obstructive azoospermia from nonobstructive azoospermia in infertile men”

“… we have shown for the first time that in patients suffering from azoospermia, sperm quality and quantity depend on tissue perfusion within the testicle

US is an important diagnostic tool in the evaluation of infertile male patients

accuracy of US is operator-dependent and one must be aware of the limitations of this diagnostic modality

it is ideal for the treating urologist to perform his own ultrasonographic studies when possible➜ the interpretation of these studies may be influenced by

clinical data not available or familiar to radiologists

role of US in the assessment of male infertility

however, one should remain cautious about the over interpretation of ultrasonographic studies and refrain from injudicious use of this safe and relatively inexpensive imaging modality

the results of these studies may lead to inappropriate surgical interventions that are expensive and involve significant risk

role of US in the assessment of male infertility

l’imaging quale premessa alla clinica dell’infertilità · abnormalities in the human male...

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